Provider Demographics
NPI:1053788240
Name:J. TODD WILLIS, MD CLINIC
Entity type:Organization
Organization Name:J. TODD WILLIS, MD CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:SAVELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-663-1285
Mailing Address - Street 1:1003 HOLLAND AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2180
Mailing Address - Country:US
Mailing Address - Phone:601-656-0010
Mailing Address - Fax:601-656-0313
Practice Address - Street 1:1003 HOLLAND AVENUE
Practice Address - Street 2:SUITE 104
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2180
Practice Address - Country:US
Practice Address - Phone:601-656-0010
Practice Address - Fax:601-656-0313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12556208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty